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MICHELLE'S PHARMACY, INC
CHC22690-01 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Macoupin County Public Health Clinic Site
Type
HRSA-Funded Health Center
340B ID
CHC22690-01
Entity Address
1115 E. Morgan Street
Carlinville, IL 62626-1430
Grant Number
H80CS22690
Participating Start Date
1/1/2020
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
MICHELLE'S PHARMACY, INC
Pharmacy Address
120 S MACOUPIN ST
GILLESPIE, IL 62033
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Kent Tarro, CEO
(217) 825-6705
Contract Pharmacy Representative
Michelle's Pharmacy, Inc.
Michelle Dyer, President
(618) 585-1293
Signed By Date
10/11/2019
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